Use of adenosine compounds for autonomic nervous system attenuation

ABSTRACT

A method of inducing anesthesia, sedation, analgesia, hypothermia, and reduced stress by administering an effective amount of an adenosine compound to a mammal. It also provides a method for preserving donor organs in vivo by contacting them with an adenosine compound, as well as a method for preparing organ recipients for transplant.

This application is a divisional of U.S. application Ser. No.08/437,080, filed May 5, 1995, which is a continuation of U.S.application Ser. No. 08/203,670, filed Feb. 28, 1994, now abandoned,which is a continuation of U.S. application Ser. No. 08/083,214, filedJun. 25, 1993, now abandoned, which is a continuation of U.S.application Ser. No. 07/756,480, filed Sep. 9, 1991, now abandoned,which is a continuation-in-part of U.S. application Ser. No. 07/521,529,filed May 10, 1990, now abandoned.

BACKGROUND OF THE INVENTION

1. Field of The Invention

This invention relates to a method of using adenosine compounds toinduce anesthesia, sedation, analgesia, hypothermia, and to amelioratestress.

2. Related Art

A patient is protected from the pain and stress of surgery and similarprocedures by anesthesia which allows the maintenance of physiologicalhomeostasis.

Adenosine has a variety of extracellular effects. It is known to havepotent vasodilating, blood pressure lowering (hypotensive) andshock-inducing effects, but has never been demonstrated to haveanesthetic activity when used clinically. Furthermore, the conventionalwisdom is that neither adenosine nor adenosine triphosphate (hereinafterATP), an adenine nucleotide, circulating in the blood, will cross theblood brain barrier. Therefore, despite analgesic and sedative effectssuggested by previous studies in laboratory experiments, neitheradenosine nor ATP had ever been thought to be suitable as anesthetics. Amajor problem with prior studies is that they were performed under suchpoorly controlled conditions that the vital signs: circulatory, such asblood pressure, heart rate and respiratory functions were not measured.Because data on the behavior of these parameters are essential indetermining therapeutic efficacy, these studies failed to teach whethersuch potential analgesic and sedative effects were caused by theprofound effects of these compounds on cardiovascular function, namely:hypotension, coma, bradycardia, or shock. Failure to determine the vitalsigns, and to isolate the analgesic properties from the coma or shock,which may be produced by potent hypotensive effects of adenosine, renderthese reports fatally flawed as teaching analgesia or sedation caused byadenosine. Consequently, previous studies do not evaluate usage fortreatment purposes of these agents. Based on previous reports, sucheffects (analgesia, sedation) could not possibly have been translated toclinical applicability.

A variety of drugs are presently used to provide anesthesia. Goodman andGilman's The Pharmacological Basis of Therapeutics, 7th Ed., 1985,MacMillan, N.Y., Chapters 13 and 14 provide an overview of the field ofanesthesiology as currently understood by those skilled in the art.

Total replacement or dose reduction of other anesthetics have definiteclinical advantages such as decreased toxicity and rapid recovery fromanesthesia. These advantages can be realized because inhalational orother synthetic chemical anesthetics are often toxic even when used atthe required effective dose and can produce severe cardio-respiratoryand metabolic side effects. Secondly, the amount of anesthetic actuallybeing used by the patient is subject to guesswork in the operating room.

Adenosine and ATP are endogenous compounds and, as a consequence, areunlikely to produce toxic effects. Both adenosine and ATP are known tobe rapidly metabolized and eliminated from the blood stream; when theinfusion is stopped, recovery starts immediately and proceeds rapidly.Therefore, either adenosine, ATP, or functionally similar adenosinecompounds would be ideal replacements for inhalational anesthetics, andreplacements for opioid analgesics.

In the present invention, it has been possible to isolate anddemonstrate the intrinsic anesthetic properties of adenosine compounds.Applicant has found that under normal blood pressure and normalmetabolic and respiratory functions, administration of an adenosinecompound, such as adenosine and ATP, produced potent analgesic,sedative, and stress inhibiting effects, such as antihypertension andblood pressure control. Furthermore, such administration amelioratedundesirable cardiovascular and respiratory functions deteriorated byother anesthetics during anesthesia indicating that such adenosinecompounds are superior anesthetic agents. This finding is unexpected andsurprising because these agents are known to be potent hypotensive,bradycardic, and shock-inducing agents which clinicians would try toavoid.

Furthermore, when a subject anesthetized with an adenosine compound isthen subjected to body temperature decrease, the decrease is notaccompanied by shivering, cardiovascular distress, or pulmonarydistress. This effect holds for drops in body temperature at least aslarge as 10° C. to 20° C.

Adenosine compounds have also been discovered to provide excellent bloodand tissue oxygenation. As such, an adenosine compound can be used tomaintain donor organs for transplant in the best possible conditionwhile still in the donor body and the period of time between removalfrom the donor body and implantation. Furthermore, the excellent bloodand tissue oxygenation induced by the adenosine compound can be used tomaintain the organ and the organ recipient in the best possiblecondition.

SUMMARY OF THE INVENTION

This invention provides a method of inducing anesthesia, sedation,hypothermia, and analgesia, and a method of treating stress andhypothermia by administering an effective amount of an adenosinecompound to a mammal in need of anesthesia or analgesia, or requiringinduction of, or relief from, hypothermia. It also provides a method forpreserving donor organs in vivo by contacting them with an adenosinecompound, as well as a method for preparing organ recipients fortransplant.

An aspect of this invention is a method of anesthetizing a mammalcomprising administering an adenosine compound for the period thatanesthesia is desired.

A further aspect of this invention is a method of creating subnormalbody temperatures in a mammal comprising: (1) administering an adenosinecompound; (2) exposing the body of the mammal to a sub-normaltemperature ambient temperature; (3) allowing the body temperature ofthe mammal to fall; and (4) rewarming the mammal to normal bodytemperature.

Yet a further aspect of this invention is a method of relieving paincomprising administering an analgesically effective amount of anadenosine compound to a mammal for the period of time during which painrelief is desired.

Another aspect of this invention is a method of relieving stress, andstress response by administering an adenosine compound for the period oftime during which stress and stress response relief is desired.

Another aspect of this invention is a method of providing in vivopreservation of donor organs, as well as organ transplant recipients, bymaintaining good tissue oxygenation to the mammal and the organs,comprising the administration of an adenosine compound for a period preand post-organ transplantation.

A further aspect of the invention is a method of sedating a mammal whichcomprises administering an adenosine compound for the period of timeduring which sedation is desired.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 compares the anesthetic effects of various agents by measuringhypnotic and analgesic responses.

FIG. 2 illustrates the amount of anesthetic effect of ATP, measured asenflurane MAC.

FIG. 3 shows the analgesic effect seen with morphine sulfate andadenosine.

FIG. 4 shows the inhibition of stress response in blood pressure to thenociceptive electrical stimulation.

FIG. 5 shows the blood pressure responses and the sedative and analgesiceffects of ATP for prolonged time.

FIG. 6 is a graphical comparison of the effect of stress on blood andtissue oxygen levels.

FIG. 6a shows the effect of hemorrhage;

FIG. 6b shows the effect of isoflurane; and

FIG. 6c shows the effect of ATP.

FIG. 7 illustrates the relationship between body temperature and timefor various doses of adenosine and ATP.

FIG. 8 shows the anesthetic effects of ATP in terms of MAC in surgicalpatients.

FIG. 9 shows hemodymic stability in surgical patients undergoing ATPanesthesia.

FIG. 10 shows the effects of ATP in decreasing enflurane requirements insurgical patients.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

As used herein, "anesthesia" is defined as the final result of severalinteracting, but independent effects. The first effect is sedationand/or sleep induction; the second is analgesia or pain relief;, thethird is stress reduction to preserve physiological homeostasis, mostfrequently seen as blood pressure and heart rate modification duringsurgery; and finally, the fourth is usually considered to be musclerelaxation, particularly relaxation of skeletal muscle. At the presenttime, no single agent provides adequate levels of each and all of thesefour effects with an acceptable margin of safety, so combinations ofdrugs must be used in cases like surgery. Anesthetic as used herein willrefer to any single drug that gives rise to at least two of the foureffects.

The term "adenosine compound" denotes compounds such as adenosine andadenine nucleotides, as well as derivatives and analogs of adenosine andATP. As used herein, the "adenine nucleotides" are adenosinemonophosphate, adenosine diphosphate, and adenosine triphosphate. Ingeneral, the preferred adenine nucleotide is adenosine triphosphate(ATP).

As used herein, "surgery" and "surgical procedures" refer broadly toinvasive discomfort-producing medical procedures. Included in thedefinition are such procedures as endoscopy, angiography, dental work,such as tooth extractions, as well as what is traditionally thought ofas surgery, for example, appendectomies and the like. Also included inthis definition is the presurgical phase and the post-surgical phase aswell as, for example, the emergency room, the intensive care unit, andthe like. As used herein, the terms broadly encompass thephysiopathological states involving alteration in existing rhythmicalprocesses that are homeostatic in nature.

Adenosine or its stable analogues can be administered by standardmethods of administration, including but not limited to intravascularinjections, intramuscular injections, oral ingestion via tablets,capsules or liquids, suppository implantations, inhalation, transdermal,nasopharyngeal, or mucosal absorption, or by continuous infusionutilizing biodegradable or non-biodegradable implantable devices. Anymethod of administration that is able to provide a plasma leveleffective to result in anesthetic, analgesic, sedative, hypothermic, orstress relief effects are suitable for the present invention.

"Continuous infusion" refers to intravascular infusions, intrathecalinfusions, and like methods of providing a continuous drug dosage over aperiod of time. Continuous infusion can also be achieved utilizing abiologically-compatible device such as a manual or continuous pumpsystem or an in vivo insertable chemical matrix containing the adenosinecompound.

The method of the invention allows those skilled in the art to inducevarious physiological states using adenosine compounds. Many of thesestates are associated with providing relief from pain. The particularstate induced to relieve pain can vary from a diminished awareness orperception of pain (e.g., analgesia) where there can be completeconsciousness to a state where there is grogginess (e.g., sedation), toa state where there is a loss of consciousness (e.g., generalanesthesia). Anesthesia can be further characterized as regional orlocal, where there is consciousness, but no awareness or sensation ofpain. In the methods of the present invention, terms such as"anesthetically effective", "analgesically effective", and "sedativelyeffective", are used to describe that dose of adenosine compound neededto induce such states while maintaining the circulatory, respiratory,and metabolic functions within normal ranges. Those of skill in the artunderstand the appearance of these various states and know when apatient's functions are within the normal ranges. Thus, by monitoringthe vital signs, the clinician can determine the state of the patient.

As used herein, "stress" refers to the physiological changes thataccompany trauma such as surgery and physiopathological states involvingalterations in existing rhythmical processes which are homeostatic innature. It includes release of catecholamines, induction ofhypertension, hypotension, vasoconstriction, vasodilation, and the like.The term "inhibitorally effective amount" when applied to stress refersto the concentration of adenosine compounds which is administered toinhibit, or lessen, the stress response within normal ranges of thecirculatory and respiratory functions.

The present invention arose from the discovery that anesthesia,analgesia, sedation, and stress response inhibition could be induced byadenosine compounds independently of the profound hypotensive effectsassociated with these agents. However, this conclusion was reached aftercareful investigation which required the development of an experimentalmethodology that allowed the investigator to "dissect" the variousanesthetic effects of adenosine while simultaneously monitoring thevital signs. The conventional tail clamping technique (standard methodused to test anesthetic potency) has limitations and cannot establishthe selectivity of the anesthetic responses by adenosine compounds. Thatmethod includes tactile, pulling, propioceptive as well as painstimulation, and cannot assess the responses to stimuli in a morespecific manner. By using the electrical stimulation methodology, it waspossible to differentiate the arousal (hypnotic) responses from thepurposeful escape movement (analgesic) responses to painful stimuli. Theresults indicated that adenosine compounds can selectively inhibit thepain and hemodynamic responses. Moreover, the experimental techniqueallows the testing of the efficacy and safety of anesthetic agents. Thismethodology can be used to screen an adenosine compound to determine ifit can be used according to the method of the invention. The use ofadenosine compounds without being carefully titrated or without propercardiovascular monitoring can result in dangerous, life-threateningconditions to the subject or patient. It has now been establishedthrough, experimental and clinical testing that the effects of adenosineas anesthetic, analgesic, sedative, hypothermic, and stress inhibitorare predictable and dose dependent. These results indicate that the useof adenosine compounds is safe for humans and that the dosage can beselected by the clinician administering the drug. Effective dosages ofadenosine compounds can be readily determined by monitoring the effectof a given dose on the blood pressure, heart rate, and arterial bloodgases, as described herein.

Adenosine is known to have a short plasma half life. In order to achievethe process of this invention safely, a continuous infusion of adenosineor an adenine nucleotide can be used. An infusion of approximately 1 to5500 μg of adenosine/kg body weight/min (hereinafter μg/kg/min), morepreferably, 5 to 1000 μg/kg/min, even more preferably between 50 to 500μg/kg/min, provides the effect of the invention.

The anesthetic effects of this invention are compared to standardinhalational anesthetic effects in terms of dose reduction in minimumalveolar concentration (MAC) of the inhaled anesthetics. MAC representsan index of anesthetic potency for comparison between differentinhalational anesthetic drugs. After inhalation, only relatively smallamounts of anesthetic gas is absorbed before the gas is exhaled.Therefore, those skilled in the art of anesthesiology define one MAC ofa gaseous anesthetic at 1 atmosphere of pressure (760 torrs) as thatamount which produces immobility in 50% of patients or animals exposedto painful stimulus. The use of MAC provides a convenient means ofcomparing file effect of the standard gaseous anesthetic agents,halothane, enflurane, methoxyflurane, isoflurane, and nitrous oxide tothe anesthetic effect of the adenosine compounds.

The anesthetic and analgesic properties of the adenosine compounds aremore easily compared to the effective dose of opioid analgesics. There,a dosage of opioid sufficient to produce immobility in 50% of patientsor animals exposed to painful stimuli is defined as-the effective dose(hereinafter, ED50).

Referring to TABLE 1, various anesthetics and anesthetic agents arecompared for efficacy (1) in producing sleep, (2) inducing analgesia,(3) reducing surgical stress, and (4) relaxing muscles. These are thefour effects that anesthesiologists try to achieve during a surgicalprocedure. The chart confirms that no presently used agent is effectivefor all four effects. All known agents for stress relief are notincluded in the chart because most of these agents are normallyconsidered to be cardiovascular medications, given primarily to treatcardiovascular disease, rather than anesthetic agents.

                                      TABLE 1                                     __________________________________________________________________________                CHEMICAL AGENT                                                                Halothane                                                         Component of                                                                              Enflurane                                                                          Nitrous   Neuroleptics,                                                                           Muscle                                                                             Adenosine                           Anesthesia  isoflurane                                                                         Oxide                                                                             Barbiturates                                                                        Tranquilizers                                                                       Opioids                                                                           Relaxants                                                                          Compounds                           __________________________________________________________________________    Sleep       3    1   3     2     2   0    2                                   (unconsciousness,                                                             amnesia, sedation)                                                            Antinociception                                                                           1    1   1     1     3   0    3                                   (analgesia, less pain                                                         perception)                                                                   Inhibition of Stress                                                                      1    1   1     1     1   0    3                                   (autonomic responses:                                                         blood pressure, heart rate;                                                   endocrine and metabolic                                                       responses)                                                                    Muscle Relaxation                                                                         1    0   1     1     0   3    1                                   TOTALS      6    3   6     5     6   3    9                                   __________________________________________________________________________     Anesthesia Score: 0 no effect; 1 minimal; 2 mostly; 3 maximal            

In TABLE 1, a class of agents is rated for each of the four effects andgraded on a scale of 0, indicating no effect, to 3, indicating a largeeffect. It can be seen that sleep is best sustained by the inhalationagents (e.g., halothane, and the like) and induced by barbiturates(e.g., sodium pentothal, and the like). Pain is most effectivelyrelieved by the opioid analgesics (e.g., morphine, fentanyl, and thelike). Muscle relaxation is typically induced by a paralytic agent(e.g., pancuronium, succinyicholine chloride, and the like). Each agenthas two or more points of poor effectiveness, as shown by a 0 or 1 onthe chart. As a result, in a surgical procedure, an anesthesiologistmust use several different agents to achieve successful anesthesia. Inparticular, no currently used anesthetic agent has much effectivenessagainst the stress induced by surgery.

Adenosine compounds, on the other hand, are seen to provide excellentanalgesia and stress relief, good sedation induction and maintenance,and fair muscle relaxation. Adenosine compounds work synergisticallywith other drugs thereby potentiating their properties. It should beunderstood that the adenosine compound can be administered incombination with other drugs at the discretion of the practitioner.Consequently, the dose of adenosine administered in a given situationmay vary considerably depending on the presence of one or more otheranesthetic agents. Determination of the appropriate dose in a particularinstance is empirically ascertained by the practitioner using standardmedical techniques known in the art.

An anesthetic procedure for surgery combines several effects. Itprovides pain relief, sedation, and sleep, and induces musclerelaxation. Typically, an anesthesiologist must relieve pain by anopioid or other analgesic, induce sleep by sodium pentothal or similarhypnotic, sustain sleep by an inhalational anesthetic, and relax musclesby the use of succinyl choline chloride or the like.

The method of the invention teaches the use of an adenosine compound toinduce sedation, maintain sleep, reduce stress of surgery, and relievepain while maintaining the circulatory and respiratory functions withinnormal ranges. In addition, the adenosine compound can inducehypothermia, rewarming (i.e., a return to normal body temperature), andmaintain tissue perfusion and oxygenation. Therefore, by using theadenosine compounds according to the method of the invention, theadenosine compound comes closer to being an ideal anesthetic forsurgical use and an effective drug for relief of pain, to inducesedation, and reduce stress.

Using the method of the invention, the adenosine compound may be theonly agent required for certain uses, such as relief of chronic pain, orminor surgery where deep sleep is not necessary, but pain relief is afactor. Major surgery may require the additional use of someinhalational or intravenous anesthetics and some muscle relaxant.

When the analgesic effects of adenosine compounds, such as adenosine andATP, were compared with the opioid compound, morphine sulfate, it wasfound that the adenosine compound was more potent without showingceiling effect or respiratory depression observed by narcotics. Theeffective dosage range is an infusion from about 1 μg/kg/min to about1000 μg/kg/min, preferably from about 50 μg/kg/min to about 500μg/kg/min.

The adenosine compounds, adenosine and ATP, have been found to inhibitthe CNS and the cardiovascular stress responses. They inhibitcatecholamine release, hypertension, and vaseconstriction. They improvethe cardiac function by after lead reduction when used as adjuvants toconventional anesthetics or hypnotic drugs. Furthermore, administrationof the adenosine compound does not produce tachyphylaxis or depresscardio-respiratory function. The effective dosage range is an infusionfrom about 5 μg/kg/min to about 3000 μg/kg/min, preferably from about 20μg/kg/min to about 600 μg/kg/min.

The anesthetic effects of an adenosine compound are determined byreducing the minimum alveolar concentration (MAC) of the inhaledanesthetics. For example, reducing enflurane MAC while administering anadenosine compound to achieve similar anesthesia or equipotentanesthesia. This process is done stepwise until total replacement of oneinhalation agent is made, and while still achieving equipotentanesthesia. The effective dosage range is an infusion from about 5μg/kg/min to about 1500 μg/kg/min, more preferably from about 30μg/kg/min to about 500 μg/kg/min.

The sedative effects of adenosine compounds were observed byadministering continuous infusions from about 1 μ/kg/min to about 1000μg/kg/min. However, in the presence of noxious stimuli, the effectivedosage was from about 5 μg/kg/min to about 1500 μ/kg/min, the preferreddosage being from about 5 μ/kg/min to about 500 μg/kg/min.

The tissue oxygenation effect was determined by measuring the oxygenpressure of vital organs such as the heart, brain, liver, kidney, andmuscle tissues. Polarographic oxygen electrodes are used to monitor andmeasure the oxygen pressure of the tissue, and they were comparedbetween different methods during severe stressful conditions such ashypotension. The effective dosage of adenosine compound is from about 5μg/kg/min to about 2000 μg/kg/min.

The hypothermic and rewarming effects of an adenosine compound aretested in experimental animals prepared similarly as in the rabbit modeldescribed herein to test for anesthetic effects, except that the bodytemperature is allowed to fall. In animal studies (rabbit) where theroom has a temperature of approximately 22° C., the body temperaturewill fall from a norm of about 39° C to about 32° C. in about threehours. If the animal is cooled further with ice bags, a temperature ofapproximately 22° C. can be achieved in three hours withoutcardiovascular decompensation. Rewarming is done with the aid of athermal blanket and heat lamp. The effective dosages of adenosinecompound ranged from about 100 μg/kg/min to about 5000 μg/kg/min.

The dosage ranges for the ,administration of the adenosine compoundsaccording to the method of the invention are those large enough toproduce the desired effect in which the desired physiologic state(e.g.,, anesthesia) is attained. The dosage should not be so large as tocause adverse side effects, such as hypotension, and the like.Generally, the dosage will vary with the age, condition, sex, and extentof the disease in the patient and can be determined by one of skill inthe art. The dosage can be adjusted by the individual physician in theevent of any counterindications.

The adenosine compounds can be administered parenterally by injection orby gradual perfusion or infusion over time. The adenosine compounds canbe administered parenterally by such mutes as intravascularly,intrathecally, epidurally, intrapertitoneally, intramuscularly,subcutaneously, intracavity, transdermally, epidermally,nasopharyngeally, or mucosally. Alternatively, the adenosine compoundscan be administered enterally, as by oral administration.

In contrast to other conventional anesthetics, the adenosine compoundsare useful over a wide dose range. For example, adenosine is active overa range of between 1 to 5000 μg/kg/min. In contrast, conventionalanesthetic agents, such as isoflurane, have narrow effective ranges. Thefatal to effective anesthetic ratio of isoflurane is 3.02±0.13. Otherreports indicate that isoflurane has about 1.88 times the safety rangeof halothane. When these ranges are stated simplistically, they suggestthat if a patient is administered between two and five times the doserequired for the onset of sleep, the patient will die. Of course, theanesthesiologist will err on the side of administering too little and,thereby, runs the risk of underdosing the patient. This need for cautionmay result in an inadequately anesthetized (subanesthetized) patientduring the surgical procedure.

One great advantage observed with adenosine compounds is the wide marginfor error on effective therapeutic range. This advantage is exemplifiedby adenosine where the lethal dose is about 100 times the dose requiredfor analgesia, and ATP where the lethal dose is greater than 150 timesthe amount required for analgesia. In fact, in the case of ATP, theratio remains unknown in the studies reported herein,. since noexperimental animals died even when given enormous overdoses.

Formulations

Preparations for parenteral administration include sterile aqueous ornon-aqueous solutions, suspensions, and emulsions. Examples ofnon-aqueous solvents are propylene glycol, polyethylene glycol,vegetable oils such as olive oil, and injectable organic esters such asethyl oleate. Aqueous carriers include water, alcoholic/aqueoussolutions, emulsions, or suspensions, including saline and bufferedmedia. Parenteral vehicles include sodium chloride solution, Ringer'sdextrose, dextrose and sodium chloride, lactated Ringer's, or fixedoils. Intravenous vehicles include fluid and nutrient replenishers,electrolyte replenishers (such as those based on Ringer's dextrose), andthe like. Preservatives and other additives may also be present such as,for example, antimicrobials, anti-oxidants, chelating agents, and inertgases and the like.

Liquid dosage forms for oral administration will generally comprise theadenosine compounds alone or in a composition additionally containinginsipients such as emulsions, suspension, solutions, syrups, and elixirscontaining inert diluents commonly used in the art, such as purifiedwater, sugars, polysaccharides, silicate gels, gelatin, or an alcohol.In addition to the inert diluents, these compositions can also includefactors such as wetting agents, emulsifying and suspending agents, andsweetening, flavoring, and perfuming agents.

The above disclosure generally describes the present invention. A morecomplete understanding can be obtained by reference to the followingspecific examples which are provided herein for purposes of illustrationonly and are not intended to limit the scope of the invention.

EXAMPLE 1 SCREENING OF ADENOSINE COMPOUNDS

This study describes a methodology which can be used to screen andidentify adenosine compounds which can be used according to the methodof the invention. A screening test to evaluate the therapeutic use ofadenosine compounds ideally includes such parameters as: (1) noxiousstimuli (e.g., tail clamp, electrical stimulation); (2) respiratoryparameters (e.g., respiratory rate); (3) arterial blood gases (e.g.,PaCO₂, PaO₂); (4) metabolic parameters (e.g., pH, BE); and (5)circulatory parameters (e.g., SBP, DBP, MBP, heart rate).

Anesthetic agents were assessed by using the electrical tail stimulationin the rabbit. The use of electrical stimulation as a way to producenoxious stimuli is an alternative to tail-clamping. It offers a methodof applying noxious stimuli gradually in a quantifiable manner. Bychanging the intensity, two distinct behavioral responses are noted: (a)head lift (HL), an arousal response shown by opening the eyes andlifting the head (hypnotic index); and (b) purposeful escape movement(EM) away from the noxious stimuli (analgesic index). The responses inthreshold voltages can be plotted on one axis, and the dosages can beplotted in the other axis.

In evaluating the adenosine compounds, unmedicated, healthy adult NewZealand white rabbits of either sex, weighing 4-5 kg were studied. Therabbits were first anesthetized by halothane 3-4% in oxygen via a circlesystem. Udocaine 1% supplemented the halothane anesthesia whentracheostomy was performed and a 3.5 cuffed pediatric endotracheal tubewas inserted into the trachea. The halothane concentration was thenreduced to 2% in oxygen during the rest of the preparation period and nomuscle paralyzing drug or an opioid analgesic was used at all. Allanimals were allowed to breathe spontaneously throughout the study.Expired halothane and carbon dioxide concentrations were monitoredcontinuously using a Datex Anesthetic Agent Monitor 222(Puritan-Bennett) and a capnometer (Beckman), respectively. Two earveins and an ear central artery were cannulated with 22 gauge plasticcatheters for drug infusion, and for blood sampling. The femoral arteryand vein were cannulated and the catheters were placed with its tip inthe mid-thoracic aorta to measure central arterial and venous bloodpressures. Rectal temperature was controlled at 38.5°-39.5° C. with theaid of a heating lamp. All drugs were completely discontinued, andrecovery was awaited.

The conscious rabbits were placed in a hammock which was suspended fromfour poles via ropes in such a manner that allowed each animal's neck,head, and legs to be free to move (for a clear response to the noxiousstimuli). After complete recovery from the halothane anesthesia, controlvalues were measured and recorded. Next, a gas mixture of nitrous oxide(60%) and oxygen (40%) was breathed through the endotracheal tube tomaintain a baseline sedation. A pair of stimulating needle electrodeswere placed at the base of the shaved tail, and electrical current wasdelivered for 40-60 seconds from a nerve stimulator (Grass S48Stimulator) delivering rectangular pulses of current (1 ms, 3-5 Hz) withdifferent intensities (1-80 V) for each test. Each infusion dose wasmaintained for 20 minutes.

No muscle paralyzing drug or mechanical ventilatory assistance was usedthrough the experiments. Noxious stimuli were applied after each drugdose and maintained stable for 20 min. Neurobehaviorar responses,including degree of sedation, sleep, arousal responses (eye opening andhead lifting), and antinociceptive responses (purposeful escapemovement), were carefully observed and recorded by someone who wasunaware of the agent being tested. Also, respiratory and circulatoryparameters were measured and recorded: Systolic Blood Pressure (SBP),Diastolic Blood Pressure (DBP), Mean Arterial Blood Pressure (MAP),Respiratory Rate (RR), EKG, Body Temperature (BT). For the blood gases:pH, PCO₂, PO₂, HCO₃, BE.

Evaluation of (a) inhalation anesthetic (Halothane) (n=6), (b)intravenous analgesic (fentanyl) (n=5), and (c) adenosine (n=6) is shownin FIG. 1. The threshold responses for each drug were consistent anddisplayed typical characteristic profiles. Increasing doses of halothaneconsistently elevated the HL (hypnotic) and EM (analgesic) responses ina dose-dependent manner, whereas fentanyl and adenosine elevated EMresponses, but the HL responses remained low, indicating analgesicproperties. Adenosine effectively blocked the hemodynamic responses tonoxious stimulation and maintained normal respiratory and blood gasparameters. On the other hand, fentanyl depressed ventilation as thedoses were increased. Continuous infusion of adenosine for prolongedtimes did not cause drug accumulation or respiratory depression; theseunique pharmacological qualities of adenosine are desirable features inclinical anesthesia. Based on the animal behavioral and hemodynamicresponses to noxious stimuli, adenosine may be categorized as a rapidacting anesthetic with primarily analgesic properties. Using themethodology and screening test, evaluation of safety and efficacy ofother adenosine compounds as anesthetics can be accomplished routinelywithout undue experimentation.

EXAMPLE 2

In this Example, ATP was substituted for enflurane (ENF), a standardinhalational anesthetic used clinically. The circulatory and respiratoryeffect of ATP and ENF were also compared. High doses of ENF with N₂ Oattenuates responses to noxious stimuli, but causes cardio-respiratorydepression. On the other hand, ATP provided sufficient anesthesia whileavoiding cardio-respiratory depression.

Six intubated rabbits (4-5 Kg) spontaneously breathing 60% N₂ O in O₂were studied. ENF concentrations of 0.5, 1.0, 1.5, 2.0, and 2.5% wereadded to N₂ O stepwise. After equilibration of each increased ENF dose,electrical tail stimulation (1 ms, 5 Hz) in increasing (graded)intensities as tolerated up to 80 V was applied. This kind ofstimulation allowed quantifiable, and reproducible stimulation.Responses and measurements were taken every 20 minutes. In addition tothe electrical stimulation, the tail clamping technique, a standardmethod of testing anesthetic potency, was used in order to establish thesurgical level of depth of anesthesia. Furthermore, the ear and leg wereclamped with a hemostat, and pin prick with a needle was applied toreconfirm nociceptive responses. Purposeful escape movements were usedas end-points. When negative response to stimuli was achieved, the doseof ENF was decreased stepwise by 0.5% until positive response was shown;then, ATP infusion was titrated to replace the decreased ENF anesthesiauntil ATP could totally and effectively replace ENF (ATP initial dose: 5μg/kg/min).

Referring to FIG. 2, animals under 60% N₂ O and increasing doses of ENFup to 1.5% showed an elevated pain threshold, but still respondedpositively to the tail clamp. ENF, at levels greater than 2-2.5%, couldcompletely inhibit such responses. At this dose, however, significantcardio-respiratory depression was seen (see TABLE 2). Addition ofincreasing doses of ATP (5-362 μg/kg/min) allowed ENF to be replacedwithout diminishing the pain tolerance. Moreover, systemic bloodpressure (SBP) and heart rate (HR) returned to control levels, butanalgesia persisted. Although adenosine and ATP have extremely shortplasma haft lives, IV ATP may have intrinsic analgesic activity in theCNS, since the selective analgesic effect persisted after the infusionhad stopped. This effect may have been due to activation of centralpurinergic receptor mechanism which, once activated, has a longduration. This was seen by the observation of sustained analgesia afterdiscontinuation of ATP which was partially reversed by IV aminophylline.This sustained analgesic property without cardio-respiratory depressionmay have marked clinical significance. These results demonstrated thatthe anesthetic effects of ATP were superior to enflurane as seen by theresponse of the cardiovascular parameters which were evaluated.

                  TABLE 2                                                         ______________________________________                                        CARDIO-RESPIRATORY DATA                                                                 O.sub.2  CONTROL    ENF    ATP                                                ONLY     (N.sub.2 O)                                                                              (N.sub.2 O)                                                                          (N.sub.2 O)                              ______________________________________                                        SBP(mmHg) 109 ± 11                                                                            126 ± 15                                                                              69 ± 22*                                                                          112 ± 20                              DBP(mmHg) 83 ± 5                                                                              85 ± 4  49 ± 18*                                                                          83 ± 16                               HR(bpm)   270 ± 13                                                                            267 ± 15                                                                              255 ± 33*                                                                         278 ± 26                              RR(bpm)   76 ± 5                                                                              85 ± 5  72 ± 19*                                                                          81 ± 14                               PaCO.sub.2 (mmHg)                                                                       25 ± 4                                                                              22 ± 2  25 ± 1*                                                                           22 ± 3                                PaO.sub.2 (mmHg)                                                                        443 ± 68                                                                            147 ± 11                                                                              148 ± 16                                                                          145 ± 24                              ______________________________________                                         RR: Respiratory Rate, O.sub.2 : 100%, N.sub.2 O: 60%, ENF: 2.0-2.5%, ATP:     32 ± 164 (μg/kg/min), Mean ± SD                                      *p < 0.05 vs CONTROL · (n = 6)                                  

EXAMPLE 3

In this Example, the analgesic activity, the dose requirement, and thepotency ratio of adenosine and morphine sulfate are compared.

The evaluation used six intubated rabbits (4-5 Kg) spontaneouslybreathing 60% N₂ O in O₂. Two forms of noxious stimuli were evaluated:(1) clamping the tail and the ear with a rubber-shod hemostat, and (2)electrical impulsing in increasing intensity, as tolerated, to a maximumof 80 v. This allows quantifiable, reproducible stimulation. Responsesassessed were: HR, SBP, respiratory rate (RR), neurobehavior, andpurposeful escape movements. After 20 min of 60% N₂ O, control responsesto stimulation were recorded. Adenosine was infused peripherally atincreasing dosage until significant alterations in response tostimulation occurred. Normotension was maintained without pressuresupport. Duration and intensity of analgesia was evaluated every 15 minafter termination of infusion. Aminophylline was given to reverseanalgesic effects. Morphine sulfate was then titrated IV to max 2 mg/kgto attain a surgical level of analgesia (ED50 evaluated by the tailclamp response). No further doses were given if severe respiratorydepression occurred.

Despite inhalation of 60% N₂ O, all animals responded with purposefulescape movements to tail and ear clamp, and electrical stimulation.Addition of adenosine in doses of 188±20 μg/kg/min completely suppressedthe responses to both kinds of stimulation (ED90). No motor orcardio-respiratory depression occurred, and no ceiling effect was noted.Aminophylline (5-10 mg/kg) consistently reversed adenosine inducedanalgesia: With morphine sulfate to 2 mg/kg, no animal had completesuppression of all responses. Referring to FIG. 3, a comparison of theeffective analgesia of morphine sulfate and adenosine is shown. Theeffect of morphine sulfate appears to approach an asymptotic limit,thereafter giving no greater relief from pain (as measured by thevoltage (v) of an electric stimulation), whereas adenosine provides moreand more relief from pain.

                  TABLE 3                                                         ______________________________________                                        CARDIO-RESPIRATORY DATA                                                                   CONTROL    ADENOSINE   MORPHINE                                   ______________________________________                                        BP(mmHg)    97 ± 12 101 ± 19 105 ± 14                                HR(bpm)     240 ± 30                                                                              230 ± 24 242 ± 72                                RR(bpm)     89 ± 10 85 ± 19  47 ± 16*                                PaO.sub.2 (mmHg)                                                                          136 ± 15                                                                              126 ± 8  123 ± 14                                PaCO.sub.2 (mmHg)                                                                         22 ± 4  25 ± 4   31 ± 3*                                 ______________________________________                                         n = 6, Mean ± SD, BP: Systolic BP, RR: Respiratory Rate,                   *p < 0.05 vs CONTROL                                                     

This study demonstrates that adenosine, in sub-hypotensive doses,significantly raised thresholds for pain. Prolonged analgesia may bemediated by the adenosine A₁ receptor mechanism as supported by reversalof analgesia with aminophylline. Adenosine appears to have an analgesicpotency ratio of about 25:1 as compared to morphine sulfate. Adenosine'sproperty of sustained intense analgesia, absent cardio-respiratorydepression, absence of "ceiling" effect, and easy reversibility providesexcellent characteristics for its use in clinical anesthesia.

As illustrated in FIG. 4, the blood pressure was recorded as describedin Examples 2 and 3 as electrical stimulation was applied to the tail.When ATP was administered, purposeful escape movements decreased. Whensufficient ATP was infused, no further purposeful escape movements orstress were seen as reflected by the blood pressure. FIG. 5 shows theblood pressure recording of the stable hemodynamic state obtained whenATP was administered during noxious stimulation for a prolonged time.

EXAMPLE 4

This Example shows a comparison of oxygen transport and regional tissueoxygenation during induced stress response caused by hypotension byhemorrhage, isoflurane, and ,adenosine triphosphate in dogs. Thesestudies support the use of an adenosine compound in the in vivopreservation of a donor organ both in the donor mammal and in therecipient mammal after transplant, since the induced stress responsemimics the condition existing in such circumstances.

The term "preservatively effective amount" refers to the concentrationof adenosine compounds which is necessary to show as improvement in thepreservation of a donor organ.

One of the most important concerns during hypotension is the fear ofimpaired vital organ perfusion and oxygenation. This study compared thechanges in oxygen transport parameters and regional tissue oxygentension of the parenchymal and non-parenchymal organ/tissues duringgraded arterial hypotension.

Twenty-three dogs (23.1±5 kg) were anesthetized with pentobarbital (30mg/kg IV), intubated and mechanically ventilated with 40% O₂ in nitrogento maintain normocapnea under normothermia (38° C.). Arterial andpulmonary artery (Swan-Ganz) catheters were placed via a femoral cutdown. A Clark-type polarographic PO₂ electrode with a tip diameter (3mm) was inserted under the dura and placed on the frontal cortex througha small burr hole.

Another PO₂ sensor probe was placed on the surface of the liver, kidney,subcutaneous, and muscle of the chest wall through a small skinincision. Referring to FIG. 6, the dogs were divided into three groups:(a) hemorrhagic (n=7), (b) isoflurane (n=8), and (c) ATP (n=8). Meanarterial pressure (MAP) was lowered stepwise from control (119±4.5 mmHg)to 90, 70, 50, and then to 30 mmHg, each being maintained for 20minutes. The following were measured and/or calculated: MAP, O₂consumption (VO₂), O₂ delivery (DO₂) and PO₂ of arterial (PaO₂) andmixed venous (PvO₂) of the brain (PbO₂), liver (PIO₂), kidney (PkO₂),subcutaneous (PscO₂), and muscle (PmO₂) of the chest wall. The data wereanalyzed using ANOVA with the Bonferroni t-test and unpaired t-testwhere appropriate, accepting p<0.05 as significant.

Results are illustrated in FIGS. 6a, 6b, and 6c. During the sequentialhypotension, PaO₂ remained unchanged. Due to autoregulation, cerebralcortical PbO₂ was little affected in all groups. However, there weremarkedly different hemodynamic and tissue oxygen responses between thethree different hypotensions. Hemorrhage caused intense peripheralvasoconstriction. Isoflurane blunted these peripheral vasoconstrictiveresponses. However, with higher dosage isoflurane seriously depressedDO₂ resulting in a reduced O₂ supply/demand ratio, while ATP maintainedbetter balanced O₂ transport profile which resulted in a positive O₂supply/demand ratio in all stages of hypotension favoring the tissueoxygenation preferentially to the vital organs.

EXAMPLE 5

This Example shows the effects of adenosine and adenosine triphosphateon hypothermia in rabbits. As used herein, the term "hypothermallyeffective amount" denotes that concentration of adenosine compoundswhich is needed to induce hypothermia, i.e., a subnormal bodytemperature.

Referring to FIG. 7, the body temperature versus time plots are shownfor eight different experiments. In Run 1, adenosine 500 μg/kg/min wasadministered intravenously to rabbits for six hours. The administrationwas then stopped and the body temperatures were allowed to recover.

In Run 2, ATP 500 μg/kg/min was administered intravenously for six Atthat time, the body temperature was 31.5° C. The animal's bodytemperature was allowed to recover by applying external heating for fourhours when (at the arrow) the external heating was removed and thetemperature was allowed to fall. The body temperature again fell.

In Run 3, ATP was administered intravenously. The body temperaturestabilized after ten hours at 32.5° C.

In Runs 4, 5, and 6, adenosine was administered to rabbits until thebody temperature reached a constant value. In Run 4, after five hours,the body temperature stabilized at 33° C. In Run 6, after six hours, thetemperature stabilized at 31.5° C.

In Run 7, five unmedicated New Zealand rabbits were anesthetized withhalothane in O₂ using a face mask. The ear vein was cannulated with a 22gauge plastic catheter for drug infusion. 500 μg/kg/min to 5500 μ/kg/minadenosine was administered IV. Body temperature was monitored through arectal thermometer. The body temperature started at approximately 38.5°C. After the application of ice bags, the temperature droppedapproximately 5.5° C./hr until a minimum body temperature ofapproximately 22° C. was achieved. During the body temperature lowering,no shivering or other apparent discomfort was observed. All five rabbitssurvived the temperature lowering.

The ice bags were removed and external heating applied. The bodytemperature of all rabbits returned to normal, and the rabbits wereapparently normal.

In a comparison, in Run 8, six rabbits were anesthetized with isofluaneand external cooling applied. At 34° C., one rabbit expired due toventricular fibrillation. At 25° C., another expired due to pulmonaryedema. All rabbits receiving isoflurane alone were observed to shiverviolently as body temperature was lowered.

EXAMPLE 6

In this Example, intrathecal administration of adenosine was shown to beeffective. Anesthesia was induced in unmedicated New Zealand whiterabbits (4-5 Kg) with 3-4% halothane in oxygen using a face mask. Thetrachea was intubated with a No. 3.5 pediatric endotracheal tube. Allthe animals breathe spontaneously throughout the study, but weremechanically ventilated when required. Rectal temperatures werecontrolled at 38.5°-39.5° C. Expired halothane and carbon dioxideconcentrations were monitored continuously. Two ear veins and an earcentral artery were cannulated with 22 gauge plastic catheters for druginfusion and for blood gas monitoring. The groin was exposed and acut-down performed on the femoral artery and vein. The femoral arterywas cannulated and the catheter placed with its tip in the mid-thoracicaorta to measure central systemic blood pressures, Another centralvenous catheter was inserted through the femoral vein.

The animal was turned in a prone position and the operative siteprepared over the lower back. The skin was infiltrated with 2% lidocaine3-4 cc. Following dissection through the paravertebral muscles, alaminectomy was performed. A touhy needle was placed under direct visioninto the sub-arachnoid space and a microcatheter (22-32 gauge) wasthreaded through the needle advancing it gently so that its tip was atthe base of the skull. Clear CSF was aspirated to confirm sub-arachnoidplacement. The laminectomy site was disinfected and sutured to close thesite. The catheter was secured with tape.

Noxious stimulation was provided by an electrode placed at the base ofthe tail for low voltage electrical current stimulation deliveredthrough a nerve stimulator. Other kinds of stimulations were in the formof a pin prick with a 20 gauge needle, pinching the paw and tailclamping with a rubber-shod hemostat.

Continuous recording of cardio-respiratory parameters including theheart rate, arterial blood pressure, respiratory rate, the animal'sphysical movement, and any other behavioral changes were recorded.Samples of arterial and mixed venous blood were analyzed for pulmonarygas exchange and acid base status.

Several intrathecal dosage forms were evaluated: lidocaine was given in0.5 mg/kg increments; fentanyl was given in 1 μg/kg increments;adenosine was given as a fractionated dose, as well as via a continuousinfusion (10 mg/hr) based on the body weight of the rabbit.

                  TABLE 4                                                         ______________________________________                                        CIRCULATORY AND RESPIRATORY CHANGES AFTER                                     INTRATHECAL* INJECTION OF ADENOSINE,                                          FENTANYL AND LIDOCAINE                                                                  ADENOSINE   FENTANYL   LIDOCAINE                                              (20 mg)     (20 μg) (4 mg)                                       ______________________________________                                        Δ MAP                                                                             -4 ± 5   +13 ± 5 -65 ± 4                                   (mmHg)                                                                        Δ HR                                                                              -22 ± 5  -65 ± 33                                                                              -25 ± 40                                  (bpm)                                                                         Δ RR                                                                              -4 ± 10  -82 ± 15                                                                              -140 ± 46                                 (bpm)                                                                         Δ PaCO.sub.2                                                                      -6.8 ± 2.1                                                                             +2.3 ± 2.5                                                                            +10 ± 2                                   (mmHg)                                                                        Δ PaO.sub.2                                                                       +10 ± 14 -11 ± 12                                                                              -48 ± 10                                  ______________________________________                                         MAP: Mean Arterial Pressure, HR: Heart Rate in beats per minute, RR:          Respiratory Rate in breaths per minute. Mean ± SD                          *Intrathecal injection in the high spinal (C1 area).                     

As shown in TABLE 4, comparison of the various drugs indicates thatintrathecal administration of adenosine was as effective as intrathecalfentanyl in reducing the response to the noxious stimulation, butwithout the cardio-respiratory effects seen when fentanyl or lidocainewere used.

EXAMPLE 7 EFFECT OF ATP ANESTHESIA ON THE CARDIO-RESPIRATORY FUNCTIONSIN SURGICAL PATIENTS

High doses of volatile anesthetics or opioids are required to suppressautonomic and hemodynamic responses to surgical stimulation. The use ofenflurane (ENF) for prolonged surgery may cause potential problemsincluding severe cardio-respiratory depression, EEG abnormalities, anddelayed awakening. This study compared the cardio-respiratory and plasmacatecholamine changes during balanced anesthesia of N₂ O-ATP-O₂ orENF-ATP-O₂ with the conventional ENF-N₂ -O-O₂ anesthesia in patientsundergoing oral surgery.

Following institutional approval, 14 ASA-1 consenting patients werestudied (FIG. 8). Patients were induced with IV thiopental (4-5 mg/kg),and endotracheal intubation was facilitated with succinylcholine (1mg/kg). All patients were allowed to breathe spontaneously with manualassistance when needed throughout the procedure. No further musclerelaxant or opioid analgesic was used. Anesthesia was initiallymaintained by inhaling a gas mixture of enflurane and 60% nitrous oxidein oxygen via a circle anesthesia breathing system. Monitoring includedcontinuous pulse oximeter, ECG (11), heart rate (HR), radial arteryblood pressure (BP), urine output, inspired and expired anesthetic gases(ENF (enflurane), N₂ O (nitrous oxide), O₂, CO₂ (Datex. Capnomac)),arterial blood gases (Radiometer), plasma catecholamines (HPLC), andnon-invasive esophageal ultrasound doppler probe (Datascope) for cardiacoutput (CO) and stroke volume (SV) measurements. ATP 2% solution(Adephos (R) Kowa) was infused into a peripheral vein via a continuoussyringe infusion pump (Terumo) to support BP and HR within 20% from thepre-anesthetic levels.

The doses used for ATP (108±21 μg/kg/min) were much lower than those toinduce deliberate hypotension. During surgery, anesthesia was maintainedinitially with 1.34 MAC ENF/N₂ O/O₂ then doses of ENF or N₂ O weregradually decreased while ATP infusion was increased and titrated untileither ENF or N₂ O was completely replaced by ATP. This resulted in newcombinations of anesthesia: Group I: ATP/N₂ O/O₂ (n=7), and Group II:ATP/ENF/O₂ (n=7).

Patient characteristics and the main results are shown in TABLES 5-7.Neurobehavioral and sympathetic responses (movement of body or arm, eyeopening, nydriasis, tearing, sweating, and catecholamine levels) werecarefully monitored by the anesthesiology team and, in addition, by anextra observer. Since patients were not paralyzed, any of the abovesigns would have been noticed if there were an inadequate level ofanesthesia at any time during surgery. No patient had intraoperativeevent recollection, nightmares or other dreams, or any other unpleasantanesthetic experience. Furthermore, most patients experienced anunexpected sustained analgesia in the recovery room.

                  TABLE 5                                                         ______________________________________                                        HAEMODYNAMIC, RESPIRATORY AND PLASMA                                          CATECHOLAMINE DATA DURING ENFLURANE/N.sub.2 O                                 AND ATP/N.sub.2 O ANESTHESIA IN SURGICAL PATIENTS                                           ENFLURANE     ATP                                                             +             +                                                               NITROUS OXIDE NITROUS OXIDE                                     ______________________________________                                        Haemodynamic:                                                                 HR (beat/min) 99 ± 16    95 ± 12                                        SBP (mm/Hg)   113 ± 21   129 ± 18                                       MBP (mm/Hg)   79 ± 22    78 ± 16                                        DBP (mm/Hg)   63 ± 18    54 ± 15                                        CO (L/min)    4.3 ± 1.6  6.7 ± 2.4*                                     SV (ml)       44 ± 21    70 ± 23*                                       Respiratory:                                                                  RR (breath/min)                                                                             16 ± 4     19 ± 3*                                        pH            7.33 ± 0.04                                                                              7.34 ± 0.06                                    PaCO.sub.2  (mmHg)                                                                          45 ± 4     39 ± 3*                                        PaO.sub.2  (mmHg)                                                                           202 ± 28   191 ± 57                                       BE            -2.0 ± 2.0 -2.4 ± 1.2                                     Plasma Catecholamine:                                                         NE (pg/ml)    296 ± 166  429 ± 270*                                     EPI (pg/ml)   92 ± 90    153 ± 76                                       ______________________________________                                         Mean ± SD, *p < 0.05, N.sub.2 O: 60% in O.sub.2, Enflurane: 1.33 ±      0.42%, ATP: 113 ± 19 μg/kg/min, CO: Cardiac Output, SV: Stroke          Volume, RR: Respiratory Rate, N = 7.                                     

                  TABLE 6                                                         ______________________________________                                        HAEMODYNAMIC, RESPIRATORY AND PLASMA                                          CATECHOLAMINE DATA DURING N.sub.2 O/ENFLURANE                                 AND ATP/ENFLURANE ANESTHESIA IN SURGICAL PATIENTS                                           NITROUS OXIDE ATP                                                             +             +                                                               ENFLURANE(a)  ENFLURANE(b)                                      ______________________________________                                        Haemodynamic:                                                                 HR (beat/min) 82 ± 11    97 ± 17                                        SBP (mm/Hg)   114 ± 14   100 ± 19                                       MBP (mm/Hg)   84 ± 15    61 ± 12*                                       DBP (mm/Hg)   69 ± 14    44 ± 8*                                        CO (L/min)    5.4 ± 2.5  10.5 ± 1.3*                                    SV (ml)       65 ± 10    108 ± 23*                                      Respiratory:                                                                  RR (breath/min)                                                                             19 ± 3     19 ± 2                                         pH            7.37 ± 0.02                                                                              7.35 ± 0.02                                    PaCO.sub.2 (mmHg)                                                                           47 ± 7     44 ± 7*                                        PaO.sub.2  (mmHg)                                                                           215 ± 23   568 ± 50*                                      BE            -0.4 ± 0.9 -0.5 ± 0.9                                     Plasma Catecholamine:                                                         NE (pg/ml)    178 ± 102  351 ± 98*                                      EPI (pg/ml)   86 ± 19    150 ± 130                                      ______________________________________                                         Mean ± SD, * p < 0.05, N.sub.2 O: 60% in O.sub.2, Enflurane(a): 1.24       ± 0.48%, Enflurane(b): 0.91 ± 0.12%, ATP: 103 ± 23 μg/kg/min,     CO: Cardiac Output, SV: Stroke Volume, RR: Respiratory Rate, N = 7.      

Besides sleep and analgesia, maintenance of respiratory and hemodynamicstability during surgery, is a major objective in anesthesia. NeitherENF or N₂ O alone can provide complete anesthesia, and even theircombination is not entirely satisfactory. Replacement of either ENF ofN₂ by intravenous ATP resulted in a better anesthetic state withimproved cardio-respiratory effects. No ventilatory or blood gasdeterioration was seen during ATP infusion in spontaneously breathingpatients.

                  TABLE 7                                                         ______________________________________                                        PATIENT AND ANESTHESIA CHARACTERISTICS.sup.a                                  ______________________________________                                        14 Patients:          5 M and 9 F                                             Ages (years):         27 ± 13                                              Body Weight (Kg):     57 ± 11                                              Height (cm):          167 ± 7                                              Premedication (IM):                                                           Atropine:             0.5 mg                                                  Pentazocine:          15 mg                                                   Hydroxyzine:          75-100 mg                                               Anesthesia time (min):                                                                              273 ± 107                                            Surgery time (min):   202 ± 100                                            ATP infusion time (min):                                                                            67 ± 8                                               ATP infusion dose:    108 ± 21                                                                   (μg/kg/min)                                          Dipyridamole dose:    0.2 mg/kg                                               Urine output (ml/h):  111 ± 16                                             ______________________________________                                         .sup.a Mean ± SD                                                      

The cardiac functions: cardiac output and stroke volume were amelioratedin both ATP groups, but the ATP/ENF/O₂ group showed a tendency of lowerdiastolic blood pressure than the ATP/N₂ O/O₂ group. This may be due tothe synergistic vasodilating effects of ENF and ATP. On the other hand,ATP seems to have compensated for the sympathetic mediatedvasoconstriction of N₂. Therefore, ATP/N₂ O/O₂ appears to be a moredesirable combination.

EXAMPLE 8 USE OF ATP TO ATTENUATE STRESS RESPONSE IN HUMANS

This study examined the ability of ATP to suppress the surgical stressresponses to surgery. A rapid induction and recovery from anesthesiawithout side effects are features largely sought by anesthesiologistsand surgeons.

Following institutional approval, 34 consenting ASA-1 or 2 patientsundergoing various kinds of surgical procedures, were divided in twogroups: (A) Patients who did not require muscle relaxant and breathedspontaneously (n=20); and (B) Patients requiring muscle relaxants whowere mechanically ventilated (n-14). After a standard dose ofpremedication (atropine 0.5 mg/kg. hydroxyzine 50-75 mgintramuscularly), anesthesia was induced with intravenous thiopental (5mg/kg), and endotracheal intubation facilitated with succinylcholine (1mg/kg). Following intubation, enflurane (ENF) and nitrous oxide (N₂ O)anesthesia was initially maintained with inspired concentration of ENF(1.5-2.0%) and N₂ (67%) in oxygen (O₂). Anesthetic gases were deliveredat a constant total fresh gas flow rate of 6 liters/min (4L N₂ O+2L O₂)using an anesthesia machine (Ohmeda Modulus II, BOC) via circle CO₂absorption breathing system with a 2-liter reservoir bag. In Group B,muscle relaxation was achieved with pancuronium bromide (0.03-0.05mg/kg) as required, and the lungs were mechanically ventilated. At theend of the surgical procedure, residual muscle relaxation wasantagonized by atropine sulfate (0.02 ng/kg) and neostigmine (0.04mg/kg).

Monitoring included a precordial stethoscope, continuouselectrocardiography (ECG), heart rate, brachial automatic noninvasivecuffed blood pressure monitor, pulse oximeter, hourly urine output, andinspired and expired anesthetic gas concentration as measured by a laseranesthetic gas analyzer (Rascal. Albion Instr.). Arterial bloodgases/acid-base status were assessed with appropriate electrodes (AVL940 Blood Gas Analyzer). ATP 2% solution (Adephos (R) Kowa) wasadministered intravenously via a peripheral arm vein using a continuoussyringe infusion pump (STC 521, Terumo) at infusion rates between 30-190μg/kg/min to ensure adequate depth of anesthesia and hemodynamicstability. Thereafter, ATP doses and ENF concentrations were titrated tomaintain blood pressure (BP) and heart rate (HR) within 20% from thepre-operative values, and low concentrations of ENF were administeredand adjusted during surgery. Data are presented as mean and standarddeviation (SD) or standard error of the mean (SEM) as appropriate.Significance was tested using paired or unpaired student's t-test wereapplicable. A P value of less than 0.05 was considered significant.

Patient and anesthesia data are shown in TABLES 8-10. In combinationwith N₂ O continuous infusion of ATP effectively inhibitedcardiovascular as well as neurobehavioral responses to surgery. BP andHR were easily titrated (FIGS. 9-10) and stable hemodynamic,respiratory, and blood gas values were maintained in both groups.Intra-operative urine output was 58.7 (±43.3) ml/hr in Group A, and 71.8(±44.6) ml/hr in Group B, respectively.

                                      TABLE 8                                     __________________________________________________________________________    PATIENT AND ANESTHESIA DATA: SPONTANEOUS VENTILATION (NO MUSCLE               RELAXANT)                                                                               Body           Anesthesia                                                                         Surgery                                                                           ATP Infusion                                                                         ATP Dose                             Patient                                                                           Age   Weight         Time Time                                                                              Time   (μg/kg/min)                       No. Year                                                                             Sex                                                                              (Kg)                                                                              Surgical Procedure                                                                       (min)                                                                              (min)                                                                             (min)  Min Max                              __________________________________________________________________________    1   55 F  47  Tympanoplasty                                                                            270  220 210    30  60                               2   32 F  65  Plastic Surgery (neck)                                                                   125  80  90     50  70                               3   53 F  60  Reconstructive (face)                                                                    175  115 135    50  80                               4   42 F  62  Mastectomy 240  195 210    40  60                               5   60 M  44  Mandibular Fracture                                                                      130  90  105    50  100                              6   33 F  52  Reconstructive (face)                                                                    290  255 270    50  100                              7   24 F  46  Mandibular Surgery                                                                       140  105 105    50  100                              8   62 F  50  Mastectomy 165  105 120    50  100                              9   53 F  57  Bilateral Femur Fracture                                                                 340  275 320    50  100                              10  43 F  52  Mastectomy 180  105 130    50  100                              11  22 M  60  Reconstructive (face)                                                                    220  180 155    50  120                              12  14 F  51  Low Back Tumor                                                                           145  83  105    30  120                              13  41 F  55  Thyroidectomy                                                                            160  105 120    40  110                              14  15 M  55  Tympanoplasty                                                                            225  175 180    60  160                              15  49 F  45  Tympanoplasty                                                                            220  167 170    60  110                              16  17 M  68  Mandibular Fracture                                                                      230  187 160    50  140                              17  33 F  43  Parathyroidectomy                                                                        160  120 105    70  110                              18  48 F  46  Tympanoplasty                                                                            150  100 105    60  140                              19  20 F  48  Reconstructive (face)                                                                    250  180 215    60  90                               20  51 M  56  Parathyroidectomy                                                                        170  125 120    60  110                              Mean                                                                              38.4  53.1           199.3                                                                              148.4                                                                             156.5  51.5                                                                              103.0                            (SD)                                                                              (15.6)                                                                              (7.3)          (58.5)                                                                             (58.0)                                                                            (61.7) (10.9)                                                                            (27.2)                           __________________________________________________________________________

                                      TABLE 9                                     __________________________________________________________________________    PATIENT AND ANESTHESIA DATA: CONTROLLED VENTILATION (MUSCLE RELAXANT)                   Body         Anesthesia                                                                         Surgery                                                                           ATP Infusion                                                                         ATP Dose                               Patient                                                                           Age   Weight       Time Time                                                                              Time   (μg/kg/min)                         No. Year                                                                             Sex                                                                              (Kg)                                                                              Surgical Procedure                                                                     (min)                                                                              (min)                                                                             (min)  Min Max                                __________________________________________________________________________    1   43 F  42  Hysterectomy                                                                           160  100 110    50  100                                2   52 F  63  Cholecystectomy                                                                        315  260 250    60  160                                3   71 F  41  Liver Resection                                                                        280  223 225    60  120                                4   58 M  58  Gastrectomy                                                                            255  215 210    60  160                                5   56 F  51  Cholecystectomy                                                                        115  55  60     60  110                                6   41 F  41  Hysterectomy                                                                           145  102 105    60  80                                 7   46 F  51  Hysterectomy                                                                           115  80  70     60  110                                8   53 F  46  Cholecystectomy                                                                        100  70  55     70  120                                9   43 F  44  Hysterectomy                                                                           140  100 115    60  170                                10  55 F  60  Oophorectomy                                                                           270  205 195    60  110                                11  43 F  49  Hysterectomy                                                                           145  103 110    70  150                                12  52 F  46  Hysterectomy                                                                           170  110 120    70  140                                13  57 F  68  Cholecystectomy                                                                        130  85  95     70  160                                14  59 M  60  Sigmoldotomy and                                                              Cholecystectomy                                                                        260  215 210    60  190                                Mean                                                                              52.1  51.4         185.7                                                                              137.4                                                                             137.9  62.1                                                                              134.3                              (SD)                                                                              (8.3) (8.9)        (73.3)                                                                             (69.2)                                                                            (66.0) (5.8)                                                                             (31.6)                             __________________________________________________________________________

                                      TABLE 10                                    __________________________________________________________________________    ARTERIAL BLOOD GAS DATA BEFORE AND DURING ATP INFUSION IN                     SPONTANEOUSLY (A) AND MECHANICALLY (B) BREATHING PATIENTS                                ATP Infusion Time                                                  Pre-ATP    60 min 120 min                                                                              180 min                                                                              240 min                                       __________________________________________________________________________    GROUP A                                                                            n = 17                                                                              n = 18 n = 16 n = 3  n = 1                                         pH   7.35 (0.06)                                                                         7.33 (0.03)                                                                          7.34 (0.03)                                                                          7.36 (0.03)                                                                          7.39 (0.0)                                    PCO.sub.2                                                                          43.8 (10.4)                                                                         44.1 (6.9)                                                                           41.9 (6.6)                                                                           39.9 (8.6)                                                                           31.0 (0.0)                                    PO.sub.2                                                                           156.4 (40.7)                                                                        140.9 (38.9)                                                                         137.9 (37.3)                                                                         165.5 (24.6)                                                                         115.1 (0.0)                                   BE   -2.3 (1.8)                                                                          -3.3 (1.9)                                                                           -3.2 (2.4)                                                                           -3.0 (1.8)                                                                           -4.1 (0.0)                                    Hb   12.7 (1.7)                                                                          12.6 (1.8)                                                                           12.8 (1.8)                                                                           11.9 (2.0)                                                                           10.7 (0.0)                                    GROUP B                                                                            n = 14                                                                              n = 14 n = 10 n = 5  n = 4                                         pH   7.40 (0.05)                                                                         7.34 (0.07)*                                                                         7.33 (0.06)*                                                                         7.32 (0.04)*                                                                         7.288 (0.03)*                                 PCO.sub.2                                                                          36.5 (6.3)                                                                          40.2 (7.6)                                                                           40.1 (7.2)                                                                           41.6 (4.6)                                                                           45.4 (3.6)*                                   PO.sub.2                                                                           168.9 (25.7)                                                                        140.3 (30.9)*                                                                        142.6 (36.3)*                                                                        130.4 (26.7)*                                                                        130.1 (24.1)*                                 BE   -1.8 (1.3)                                                                          -4.2 (1.9)*                                                                          -4.8 (1.3)*                                                                          -5.2 (1.1)*                                                                          -5.4 (1.1)*                                   Hb   11.9 (1.6)                                                                          11.7 (1.8)                                                                           11.2 (2. 1)                                                                          11.8 (1.9)                                                                           11.7 (2.2)                                    __________________________________________________________________________     Mean(SD), *p < 0.05 vs PreATP                                            

Continuous infusion of ATP enabled the ENF requirement to be markedlyreduced. ENF administration was completely discontinued approximately30-60 minutes before surgery was concluded. No abnormal neurobehavioralsign of inadequate anesthesia (body or arm movement, coughing,mydriasis, tearing, sweating) was seen at any time during ATP infusion.After discontinuation of N₂ O and ATP, all patients emerged fromanesthesia smoothly, and almost immediately, responsed and followedverbal commands such as opening their eyes, opening their mouth,squeezing "my hand". No agitation, grimacing, thrashing, andback-arching was seen despite the presence of the endotracheal tube.After gentle oro-laryngeal suctioning, patients were safely extubated.Post-anesthesia recovery was smooth without experiencing nausea,vomiting, or shivering. Within ten minutes after extubation, thepatients were well oriented, clear-headed, and remained calm without anysign of respiratory depression. No patient complained of intraoperativeawareness or unpleasant experience. Patients who had previous experienceof general anesthesia felt that, in terms of postoperative well being,this was their anesthetic of choice for the future.

In addition to the hypnotic and analgesic state, rapid induction ofanesthesia and maintenance of respiratory and hemodynamic stabilityduring surgery have been major objectives in anesthesia. High doses ofvolatile anesthetics or opioids are required to suppress somatic,autonomic, and hemodynamic responses to surgical stimulation. However,the use of sufficient doses of either inhalation anesthetics or opioidanalgesics, to inhibit intense and continuous surgical stimulation forprolonged surgical procedures, may cause severe cardio-respiratorydepression, metabolic disturbances, EEG abnormalities, and delayedawakening from anesthesia which may take several hours or even days.Furthermore, emergence from anesthesia is often stormy and complicatedwith events such as persistent hypertension, hypotension, drowsiness,nausea, vomiting, airway obstruction, shivering, hypoxia, and the like.

In the present study, hemodynamic and respiratory functions were wellmaintained during ATP infusion. In contrast, erratic swings in BP and HRoccurred during nitrous oxide, ENF anesthesia, and at surgical incisionbefore ATP. A noteworthy post-operative course was characterized byabsence of excitatory and stormy emergence. The most intriguingexperience was to see the patients calm and tolerating the endotrachealtube without bucking, while responding and following verbal commandsthat allowed safe extubation. Also, while a few patients requested painmedication after surgery, most patients did not show signs of distressdue to pain, confusion, or excitation. The smooth and rapid recoveryfrom anesthesia without any sign of respiratory depression, and otherside effects such as nausea, vomiting, and shivering are significantbenefits for an anesthetic used in clinical practice.

The invention now being fully described, it will be apparent to one ofordinary skill in the art that various changes and modifications can bemade without departing from the spirit or scope of the invention.

I claim:
 1. A method of modulating the autonomic nervous system responses to noxious stimulation, comprising the step of administering to a mammal a pharmaceutical composition comprising an adenosine compound at a dosage sufficient to attenuate the autonomic nervous system responses to noxious stimulation, wherein said adenosine compound is selected from the group consisting of adenosine, adenosine monophosphate, adenosine diphosphate, and adenosine triphosphate.
 2. The method of claim 1, wherein said method further comprises the step of administering a compound selected from the group consisting of an opioid, nitrous oxide, a benzodiapine, and a halogenated anesthetic compound at a dosage sufficient to attenuate the autonomic nervous system responses to noxious stimulation.
 3. The method of claim 1, wherein the mammal is a human.
 4. The method of claim 1, wherein the dosage administered is from about 5 μg/kg/min to about 5000 μg/kg/min.
 5. The method of claim 1, wherein said noxious stimulation is selected from the group consisting of surgical stimulation and hypothermia. 